Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy?

[Association between Helicobacter pylori infection and gastroduodenal lesions in patients with chronic liver disease]

CONTEXT

The relationship between Helicobacter pylori infection and gastroduodenal lesions in chronic liver disease remains controversial.

OBJECTIVE

Evaluate the evidence of the role of H. pylori infection in gastroduodenal lesions in patients with chronic liver disease.

METHODS

Forty-six patients with chronic liver disease were matched with 27 dyspeptic persons for age and sex. The gastroduodenal lesions were portal hypertension gastropathy, erosion and peptic ulcer. All patients underwent upper endoscopy: two biopsies were taken in the antrum and in the gastric body. The biopsies were used for Giemsa staining.

RESULTS

A gastroduodenal lesions were found in 38 (82.6%) patients with liver disease and was significantly more frequent than among controls (P = 0.002). H. pylori infection was detected at histological assessment in 13 (28.2%) patients with chronic liver disease and in 17 (62.9%) controls. The odds ratio (OR) showed an interaction statistically significant between gastroduodenal lesions and chronic liver disease (P = 0.04; OR = 5.1; 95% CI = 1.6-17.3). When adjusted for the presence of H. pylori OR was significantly with H. pylori negative (OR 13.0 IC 95%, 1.4-327.9).

CONCLUSION

Patients with chronic liver disease showed higher risk of developing gastroduodenal lesions regardless of the presence of the H. pylori infection.

Microwave coagulation versus sclerotherapy after band ligation to prevent recurrence of high risk of bleeding esophageal varices in Child-Pugh's A and B patients

BACKGROUND

The combination of endoscopic band ligation (EBL) with either endoscopic injection sclerotherapy (EIS) or thermal therapy has been shown to reduce recurrence of esophageal varices compared to EBL alone. The aim of this prospective trial was twofold: 1) to evaluate the safety and efficacy of EBL used in association with microwave coagulation (MC), a thermal endoscopic therapy method, for treating esophageal varices and preventing recurrence; and 2) to compare these results to the joint application of EBL and EIS.

METHODS

Seventy cirrhotic patients with bleeding esophageal varices were treated with EBL until only thin vessels remained. Thirty-six randomly selected patients received EIS (group A) and 34 received MC (group B) until complete eradication had been achieved. Endoscopic follow-up was performed to detect recurrence. The effectiveness of the treatment was measured using variceal recurrence, rebleeding, intervention complications, and recurrence factors.

RESULTS

During follow-up evaluations averaging 34.9 +/- 11.4 months, no significant differences were found between groups A and B in variceal recurrence (27.7 vs. 17.6%, P = 0.31) or rebleeding (8.3 vs. 0%, P = 0.23). Complications were rare, with no difference detected between groups. The presence of gastric varices influenced recurrence with an odds ratio of 3.9 (95% CI 1.14-13.1, P = 0.029).

CONCLUSIONS

Application of MC to esophageal varices after band ligation is safe. The post-MC recurrence rate may be comparable to that observed following the combined treatment of EBL and EIS. The presence of gastric varices increases the risk of esophageal variceal recurrence.

[Guidelines of treatment for peptic ulcer disease in special conditions]

The pathogenesis, incidence, complication rates, response to acid suppression and Helicobacter pylori (H. pylori) eradication therapy in peptic ulcer associated with chronic disease such as liver cirrhosis, chronic renal failure, diabetes mellitus, and critically ill conditions are different from those with general population, so that the management strategies also should be differentiated. The eradication of H. pylori are not so effective for preventing recurrence of peptic ulcer in liver cirrhosis patients as shown in general population, and conservative managements such as preventing deterioration of hepatic function and decrease in portal pressure are mandatory to reduce the risk of ulcer recurrence. The standard triple therapy for H. pylori eradication are as effective in chronic renal failure patients as in normal population, but the frequency of side effects of amoxicillin is higher in the patients not receiving dialysis therapy. Delay in eradication therapy until beginning of dialysis therapy or modification of eradication regimen should be considered in such cases. High prevalence of asymptomatic peptic ulcers and increased mortality in complicated peptic ulcer disease warrant regular endoscopic surveillance in diabetic patients, especially with angiopathy. The prolongation of duration of eradication therapy also should be considered in diabetic patients with angiopathic complication because of lower eradication rate with standard triple regimens as compared to normal population. Prophylactic acid suppressive therapy is highly recommended in critically ill patients with multiple risk factors. Herein, we propose evidence-based treatment guidelines for the management of peptic ulcer disease in special conditions based on literature review and experts opinion.

General rules for recording endoscopic findings of esophagogastric varices (2nd edition)

General rules for recording endoscopic findings of esophageal varices were initially proposed in 1980 and revised in 1991. These rules have widely been used in Japan and other countries. Recently, portal hypertensive gastropathy has been recognized as a distinct histological and functional entity. Endoscopic ultrasonography can clearly depict vascular structures around the esophageal wall in patients with portal hypertension. Owing to progress in medicine, we have updated and slightly modified the former rules. The revised rules are simpler and more straightforward than the former rules and include newly recognized findings of portal hypertensive gastropathy and a new classification for endoscopic ultrasonographic findings.

Effect of early propranolol administration on portal hypertensive gastropathy in cirrhotic rats

AIM

To investigate any protective effect of early propranolol administration in the development of portal hypertensive gastropathy in cirrhotic rats.

METHODS

For the development of liver cirrhosis and portal hypertensive gastropathy, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. After two weeks of CCl(4) administration, the rats were randomly separated into two groups. In group A, propranolol was continuously administered intragastrically throughout the study, whereas in group B normal saline (placebo) was administered instead. Hemodynamic studies and vascular morphometric analysis of gastric sections were performed after complete induction of cirrhosis.

RESULTS

Vascular morphometric studies showed higher numbers of vessels in all mucosal layers in the control group. Statistical analysis revealed a significantly higher total vascular surface in the control group compared to the propranolol group, but with no statistically significant difference between the mean vascular surfaces between the groups. Our study clearly shows that the increased mucosal blood flow is manifested by a marked increase of vessel count.

CONCLUSION

Early propranolol's administration in portal hypertensive cirrhotic rats seems to prevent intense gastric vascular congestion that characterizes portal hypertensive gastropathy.

Underlying mechanism of portal hypertensive gastropathy in cirrhosis: a hemodynamic and morphological approach

BACKGROUND AND AIM

Portal hypertensive gastropathy (PHG) is an important cause of bleeding in patients with cirrhosis associated with portal hypertension. Histologically, the condition is characterized by dilation of the mucosal and submucosal vessels of the stomach; however, its mechanisms remain unclear. The aim of the present cross-sectional study was to evaluate the role of portal and systemic hemodynamic features, humoral factors and hepatocellular function in the development and severity of PHG in patients with cirrhosis.

METHODS

Forty-six patients with cirrhosis of different etiologies underwent endoscopy. Portal hypertension was evaluated by hepatic venous pressure gradient (HVPG). The gastric mucosa was analyzed using two diagnostic methods: endoscopy according to the McCormack criteria and histological by histomorphometric analysis.

RESULTS

The prevalence of PHG according to the endoscopic and histomorphometric methods was 93.4% and 76.1%, respectively. There were no statistically significant differences in HVPG measurements between the patients with mild (16.0 +/- 5.9 mmHg) and severe PHG (16.9 +/- 6.5 mmHg; P = 0.80) or between patients who did not have (15.2 +/- 8.0 mmHg) and those who had PHG (16.3 +/- 5.7 mmHg). No correlation was found between the presence or severity of PHG and systemic vascular resistance index (P = 0.53 and 0.34, respectively), Child-Pugh classification (P = 0.73 and 0.78, respectively) or glucagon levels (P = 0.59 and 0.62, respectively).

CONCLUSIONS

The present data show no correlation between the presence or the severity of PHG and portal pressure, Child-Pugh classification or systemic hemodynamics, suggesting that other factors may be involved in the physiopathology of PHG, such as local gastric mucosal factors or other underlying factors.

Effect of laparoscopic splenectomy on portal hypertensive gastropathy in cirrhotic patients with portal hypertension

AIM

This study investigated the relationship between portal hypertensive gastropathy (PHG) and splenomegaly, and the effect of laparoscopic splenectomy on PHG in cirrhotic patients with portal hypertension.

METHODS

Seventy patients with liver cirrhosis and portal hypertension were prospectively studied. Indication for laparoscopic splenectomy was bleeding tendency in 10 patients, induction of interferon in 45, treatment of hepatocellular carcinoma in seven, and treatment for endoscopic injection sclerotherapy-resistant esophagogastric varices in eight. The severity of PHG was classified into none, mild, or severe according to the classification by McCormack et al. The severity of liver disease was classified using the Child-Pugh score. All patients underwent upper gastrointestinal endoscopy before and 1 month after the operation.

RESULTS

The prevalence of PHG was significantly correlated with the severity of liver disease using the Child-Pugh score. The severity of PHG was significantly correlated with the resected spleen volume. One month after the operation, PHG was improved in 16 of 17 patients with severe PHG and in 12 of 32 with mild PHG. The Child-Pugh score showed a significant improvement (6.8 +/- 1.4 to 6.2 +/- 1.2) at 3 months after laparoscopic splenectomy (P < 0.0001).

CONCLUSIONS

PHG may be associated with splenomegaly, and laparoscopic splenectomy may have a beneficial effect on PHG, at least for a short time.

Downregulation of cyclooxygenase-1 is involved in gastric mucosal apoptosis via death signaling in portal hypertensive rats

Portal hypertension (PHT) gastropathy is a frequent complication of liver cirrhosis and one of the leading causes of death from cirrhosis. Apoptosis is widely considered to be an active energy-dependent mode of cell death and a distinct entity from necrotic cell death. It is unclear whether gastric mucosal apoptosis is involved in PHT gastropathy. Prostaglandins (PGs) produced through cyclooxygenase (COX) are thought to play a key role in protection of the gastrointestinal mucosa from injury and apoptosis. However, the role of COX in PHT gastropathy is still not clearly understood. The aims of this study were to investigate whether (1) gastric mucosal apoptosis is involved in PHT gastropathy and (2) downregulation of COX contributes to this apoptosis. In this study, we show that gastric mucosal apoptosis was remarkably increased while mucosal proliferation was inhibited in PHT rats. Gastric mucosal COX-1 was significantly suppressed at both the mRNA and protein levels, and PGE(2) was reduced in PHT rats. Further, PGE(2) treatment suppressed gastric mucosal apoptosis in PHT rats. However, gastric mucosal COX-2 levels did not differ between sham-operated rats and PHT rats. Gastric mucosal levels of tumor necrosis factor-alpha (TNF-alpha) and Fas ligand, but not TNF-related apoptosis-inducing ligand, were increased, and activated caspase-8 and caspase-3 levels were upregulated in PHT rats. The release of cytochrome c from the mitochondria to the cytosol was not observed in PHT rats. Our data indicate that downregulation of COX-1 is involved in gastric mucosal apoptosis via death signaling-mediated type-I cell death in PHT rats.

Increased heat-shock protein 90 expression contributes to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rats

BACKGROUND AND AIMS

Portal hypertensive (PHT) gastropathy results in an increased susceptibility to damage. Adaptive cytoprotection against ethanol-induced damage is impaired in the gastric mucosa of rats with portal hypertension. Excessive nitric oxide (NO) production occurs in portal hypertension and is mediated in part via heat-shock protein (Hsp)90 production. The aim of this study was to investigate the relation between adaptive cytoprotection after exposure to ethanol and gastric expression of Hsp90 in PHT rats.

METHODS

Portal hypertension was induced in rats by staged portal vein occlusion. Adaptive cytoprotection to 70% ethanol was evaluated by assessing the injury index of the gastric mucosa with or without pretreatment with 10% ethanol. Expression of Hsp90 mRNA was evaluated by real-time polymerase chain reaction, and expression of Hsp90 protein was evaluated by western blotting. The effect of Hsp90 inhibition in PHT rats was evaluated by administration of geldanamycin.

RESULTS

Gastric Hsp90 mRNA expression in PHT rats was significantly less than that in sham-operated (SO) controls. However, after 10% ethanol pretreatment, Hsp90 mRNA expression was significantly greater in PHT rats than in SO controls. In PHT rats, gastric Hsp90 protein expression after 10% ethanol pretreatment was significantly greater than that without the pretreatment. However, the pretreatment had no effect on the injury index compared to SO rats. Administration of geldanamycin prior to 10% ethanol pretreatment significantly decreased the injury index in response to 70% ethanol in the PHT rats.

CONCLUSIONS

These results show that 10% ethanol pretreatment markedly increases gastric Hsp90 expression in PHT rats. Excessive production of Hsp90 may contribute impaired adaptive cytoprotection.

Veins around the esophagus and the stomach: do their calibrations provide a diagnostic clue for portal hypertensive gastropathy?

OBJECTIVE

We analyze whether calibrations of esophagogastric veins can be used as an indirect sign for the presence of portal hypertensive gastropathy (PHG).

PATIENTS AND METHODS

The diameters of the left gastric, paraesophageal, and azygos veins were measured on magnetic resonance (MR) portograms of 57 patients with portal hypertension. The mean diameters of the above mentioned veins in patients with and without PHG were compared with Mann-Whitney U test. The diametral associations between the left gastric and azygos veins were assessed with Fisher's exact test in respect to the presence of PHG.

RESULTS

In patients with PHG, the mean diameters of the left gastric, paraesophageal, and azygos veins were not statistically different from those in patients without PHG (P>.05). There was no significant difference in the diametral relationship between the left gastric and azygos veins in patients with and without PHG.

CONCLUSION

The calibrations of the veins around the esophagus and the stomach do not provide any clue about the presence of PHG.

Pathogenesis of portal hypertensive gastropathy: translating basic research into clinical practice

Portal hypertensive gastropathy (PHG) is often seen in patients with portal hypertension, and can lead to transfusion-dependent anemia as well as acute, life-threatening bleeding episodes. This Review focuses on the mechanisms that underlie the pathogenesis of PHG that provide reasonable grounds for the treatment of this condition, and ultimately enable translation of basic research into clinical practice. Increased portal pressure associated with cirrhosis and liver dysfunction is critical for the development of clinically significant PHG, and leads to impaired gastric mucosal defense mechanisms that render the stomach susceptible to mucosal injury. The use of pharmacological agents such as beta-blockers reduces the frequency of bleeding episodes in PHG. As a last resort, surgical decompression of the portal system, transjugular intrahepatic stent placement and liver transplantation can resolve this condition. Elimination of known risk factors for gastric injury such as alcohol, aspirin and traditional NSAIDs is critical. The role of Helicobacter pylori colonization of the gastric mucosa in PHG is not clear. Careful and critical interpretation of human and experimental data can be helpful to establish a rationale for the medical management of this important condition.

Effects of propranolol on rebleeding following endoscopic esophageal variceal ligation: a prospective, controlled trial

AIM: To observe the effects of propranolol on rebleeding following endoscopic esophageal variceal ligation.

METHODS: Seventy-eight patients undergoing esophageal varices received either ligation alone (control group: n = 39) or a combination of ligation and propranolol (propranolol group: n = 39). Twelve months after ligation, endoscopic evaluation of rebleeding, portal hypertensive gastropathy (PHG), esophageal varices and fundal varices was performed.

RESULTS: At the end of 12 mo after ligation, hemorrhagic rate was significantly lower in propranolol group than in the control group (38.70% vs 54.54%, P < 0.05). PHG incidence, the incidence of gastric vein, the recurrence rate of venous reflux were significantly lower in propranolol group than in control group (32.25% vs 57.57%, 25.80% vs 42.42%, 29.03% vs 39.39%, allP < 0.05).

CONCLUSION: Propranolol reduces rebleeding after endoscopic esophageal variceal ligation, possibly through reducing the occurrences of PHG, esophageal varices and fundal varices.

Significance of ERK nitration in portal hypertensive gastropathy and its therapeutic implications

Portal hypertensive (PHT) gastric mucosa increases susceptibility to injury and delayed mucosal healing. It is possible that nitration of ERK by peroxynitrite might alter MAPK (ERK) signaling in PHT gastric mucosa, leading to delayed mucosal healing, since excessive nitric oxide production is implicated in PHT gastric mucosa and MAPK (ERK) signaling induces cell proliferation and leads to gastric mucosal healing in response to injury. Portal hypertension was produced by staged portal vein ligation, and sham-operation (SO) rats served as controls. Lipid peroxide (LPO) and nitrotyrosine increased significantly in PHT gastric mucosa compared with SO rats. ERK activation was impaired in PHT gastric mucosa in response to ethanol injury, whereas no significant difference in the phosphorylation of MEK, an upstream molecule of ERK, was seen between the two groups. The nitration of ERK by peroxynitrite, as detected by the coimmunoprecipitation of ERK and nitrotyrosine, was significantly enhanced in PHT gastric mucosa. Administration of rebamipide, a gastroprotective drug that acts as an oxygen-derived free radical scavenger, significantly decreased LPO and nitrotyrosine as well as the nitration of ERK by peroxynitrite in PHT gastric mucosa, therefore normalizing ERK activation and restoring the gastric mucosal healing response to ethanol injury. Enhanced nitration of ERK by peroxynitrite is involved in the impaired MAPK (ERK) signaling in PHT gastric mucosa. These findings demonstrate a new molecular mechanism in which PHT gastric mucosa is predisposed to injury and impaired healing.

Capsule endoscopy in the investigation of patients with portal hypertension and anemia

INTRODUCTION

Data on small bowel abnormalities in patients with portal hypertension (PHT) are limited. Bleeding from the gastrointestinal tract and anemia are common complications in these patients. Capsule endoscopy (CE) was used to evaluate small bowel (SB) pathology in patients with PHT and anemia, and possible associations with various parameters were examined.

METHODS

Thirty-five patients with PHT referred for CE investigation of the SB for anemia were prospectively enrolled in the study, as well as 70 age- and sex-matched control patients with anemia, normal liver function and no evidence of PHT who underwent CE.

RESULTS

Findings compatible with portal hypertensive enteropathy (PHE) were detected in 65.7% of the patients and in 15.7% of the controls chi2=26.641, P=0.000). Abnormalities in PHT patients included varices in 25.7%, diffuse changes of mucosa with inflammatory-like appearance in 42.9%, and angiodysplasias and/or spider angiomas in 22.9% of cases. The presence of PHE was significantly associated only with the presence of severe portal hypertensive gastropathy, while the presence of SB varices alone was significantly associated with the presence of severe portal hypertensive gastropathy, larger esophageal varices and the presence of colonic varices.

CONCLUSIONS

Varices, diffuse changes of mucosa with inflammatory-like appearance, and angiodysplasias and/or spider angiomas are detected more often in patients with PHT than in controls, and probably constitute the endoscopic characteristics of PHE. CE of the SB added a significant number of likely important findings to those detected by conventional endoscopic techniques for the clinical management of patients with PHT and anemia.

Gastrointestinal tract in liver disease: which organ is sick?

PURPOSE OF REVIEW

This article gives an overview of the several morphological and functional alterations in the gastrointestinal tract that occur in liver disease and their systemic impact.

RECENT FINDINGS

Recent endoscopic studies have revealed similar mucosal alterations in the upper gastrointestinal as well as the colon that include inflammatory-like changes and vascular lesions. Gut-barrier integrity is consequently impaired. There is an evidence that bacterial translocation with subsequent endotoxaemia provokes an inflammatory response that might trigger the cachexia syndrome in liver disease. Novel therapeutic approaches that address gut-barrier function such as supplementation with insulin-like growth factor or synbiotics have shown promising results.

SUMMARY

There are various alterations of the gastrointestinal tract in liver disease and portal hypertension, which might be less clinically overt than the cardinal potentially life-threatening features, ascites and oesophageal varices. However, these alterations, for example gut-barrier dysfunction and alterations of gut flora (microbiota) have immense impact on the portal enteropathy, as they both contribute to the systemic inflammation in liver cirrhosis, which is considered a risk factor for infections as well as the development of cachexia.

Effect of portal hypertension in the small bowel: an endoscopic approach

BACKGROUND AND AIM

The effects of portal hypertension in the small bowel are largely unknown. The aim of the study was to prospectively assess portal hypertension manifestations in the small bowel.

METHODS

We compared, by performing enteroscopy with capsule endoscopy, the endoscopic findings of 36 patients with portal hypertension, 25 cirrhotic and 11 non-cirrhotic, with 30 controls.

RESULTS

Varices, defined as distended, tortuous, or saccular veins, and areas of mucosa with a reticulate pattern were significantly more frequent in patients with PTH. These two findings were detected in 26 of the 66 patients (39%), 25 from the group with PTH (69%) and one from the control group (3%) (P < 0.0001). Among the 25 patients with PTH exhibiting these patterns, 17 were cirrhotic and 8 were non-cirrhotic (P = 0.551). The presence of these endoscopic changes was not related to age, gender, presence of cirrhosis, esophageal or gastric varices, portal hypertensive gastropathy, portal hypertensive colopathy, prior esophageal endoscopic treatment, current administration of beta-blockers, or Child-Pugh Class C. More patients with these endoscopic patterns had a previous history of acute digestive bleeding (72% vs. 36%) (P = 0.05). Active bleeding was found in two patients (5.5%).

CONCLUSIONS

The presence of varices or areas of mucosa with a reticulate pattern are manifestations of portal hypertension in the small bowel, found in both cirrhotic and non-cirrhotic patients. The clinical implications of these findings, as regards digestive bleeding, are uncertain, although we documented acute bleeding from the small bowel in two patients (5.5%).

Gastroesophageal reflux in cirrhotic patients with esophageal varices without endoscopic treatment

BACKGROUND

Portal hypertension in patients with liver cirrhosis causes manifestations such as esophageal varices, ascites and edema. Some studies have been conducted about the role of esophageal varices in the development of esophageal motor disorders and abnormal gastroesophageal reflux in these patients. Ascites could be a factor promoting gastroesophageal reflux and it has been questioned whether reflux would favor the rupture of varices. However there are a few studies using ambulatory esophageal pH recording in the evaluation of these patients.

AIMS

Evaluate gastroesophageal reflux by pH recording in cirrhotic patients with esophageal varices and possible predictors.

METHODS

Fifty one patients (28 men, 23 women, mean age of 54 years) with liver cirrhosis, diagnosed by clinical, laboratorial, image and histological findings were prospectively evaluated. All patients had esophageal varices confirmed by endoscopy and were submitted to a questionnaire about typical gastroesophageal reflux disease symptoms (heartburn and or acid regurgitation). pH recording was performed with the probe placed 5 cm above the superior lower esophageal sphincter limit, as determined by manometry. Abnormal reflux (% total time with pH < 4 >4.5%) was related to the size of varices, congestive gastropathy, ascites, severity of cirrhosis and typical gastroesophageal reflux disease symptoms.

RESULTS

The caliber of the varices was considered to be small in 30 patients (59%), medium in 17 (33%) and large in 4 (8%), 21 (41%) congestive gastropathy. Ascites was observed in 17 (33%), 32 patients (63%) were classified as Child-Pugh A, 17 (33%) Child-Pugh B and 2 (4%) Child-Pugh C. Twenty seven patients (53%) presented with typical gastroesophageal reflux disease symptoms. Abnormal reflux at pH recording was found in 19 patients (37%). One of them presented with erosive esophagitis at endoscopy. There was no relation between ascites, variceal size, congestive gastropathy and Child-Pugh score and abnormal reflux. There was a correlation between typical gastroesophageal reflux disease symptoms and abnormal reflux.

CONCLUSION

Abnormal gastroesophageal reflux was found in 37% of the patients with hepatic cirrhosis and esophageal varices. Only typical gastroesophageal reflux disease symptoms predicted these findings.

Prophylactic endoscopic sclerotherapy of large esophagogastric varices in infants with biliary atresia

BACKGROUND

Esophageal varices-related GI bleeding occurs frequently and early in life in children with biliary atresia and it may be life threatening.

OBJECTIVE

We report the results of prophylactic sclerotherapy in 13 infants with biliary atresia and large varices.

PATIENTS

Mean age was 13 months, mean weight was 8.2 kg, mean total serum bilirubin was 258 mumol/L, and mean prothrombin time was 78%. Esophageal varices were grade III (11 patients) or II (2 patients), with red signs in all infants and gastric varices in 12. None had GI bleeding.

INTERVENTION

Sclerotherapy was performed with the patient under continuous intravenous octreotide therapy in 7 infants.

RESULTS

In 8 children a complete or almost complete eradication of varices was obtained; none of these children bled later, 4 underwent liver transplantation, 3 are alive without liver transplantation, and 1 died of sepsis after 9 months awaiting liver transplantation. In 4 children a partial eradication was obtained and liver transplantation was performed. None of these children bled. One other child bled to death after 2 sessions of sclerotherapy.

LIMITATIONS

Four ulcers and 2 stenoses occurred in 6 children with no octreotide versus no ulcer and 1 stenosis in 7 children receiving octreotide.

CONCLUSION

These results (1) indicate that primary prevention of GI bleeding by sclerotherapy of esophageal varices is technically feasible and fairly effective in infants with biliary atresia and large varices, even in those with end-stage liver disease, (2) suggest that decreasing the risk of bleeding may allow liver transplantation under better conditions, and (3) further suggest that octreotide associated with sclerotherapy lowers the rate of complications.

Reduction of ethanol-induced injury in portal hypertensive gastric mucosa of rats by induction of heat shock protein 72 by geranylgeranylacetone

Portal hypertensive (PHT) gastropathy has an increased susceptibility to damage due to noxious factors. Heat shock protein (HSP) 72 has a protective effect against gastric mucosal injury and geranylgeranylacetone (GGA) is an inducer of HSP 72. However, it remains unclear how HSP 72 influences the PHT gastric mucosa. The aim of the present study was to investigate HSP 72 induction by GGA and the protective effect to gastric mucosa in PHT rats. PHT rats were produced by staged portal vein occlusion, and GGA 200 mg/kg was orally administered. Expression of HSP 72 protein in the gastric mucosa was evaluated by enzyme-linked immunosorbent assay, and gastric mucosal damage against 70% ethanol (10 mL/kg) following GGA or vehicle treatment was also estimated. Expression of mucosal HSP 72 after vehicle administration was significantly higher in the PHT rats compared with the sham-operated rats. After GGA treatment, portal pressure did not change but HSP 72 was significantly increased in the gastric mucosa of both groups. Ethanol-induced gastric mucosal damage was significantly decreased due to GGA treatment in the PHT rats, but not in the sham-operated rats. These findings suggest that HSP 72 expression is enhanced in PHT gastric mucosa and plays an important role in gastric mucosal protection. The induction of HSP 72 by GGA may therefore effectively prevent mucosal injury in the PHT stomach.

Bleeding gastric vascular ectasia treated by argon plasma coagulation: a comparison between patients with and without cirrhosis

BACKGROUND

Gastric vascular ectasia (GVE) is an uncommon etiology of GI bleeding. GVE can affect not only patients with cirrhosis but also patients with a variety of chronic diseases.

OBJECTIVE

The aim of the study was to compare clinical and endoscopic patient characteristics and responses to treatment by argon plasma coagulation (APC) of bleeding GVE between patients with cirrhosis and noncirrhotic patients.

DESIGN

Retrospective study of consecutive patients.

PATIENTS

Between January 2001 and December 2005, 30 patients were treated by APC for bleeding GVE.

INTERVENTIONS

Clinical and endoscopic features and APC treatment success were compared between patients with cirrhosis (group 1) and noncirrhotic patients (group 2).

MAIN OUTCOME MEASUREMENTS

Endoscopic treatment efficacy was assessed on the recurrence of symptoms after APC.

RESULTS

Seventeen patients were cirrhotic and 13 had no cirrhosis. Cirrhotic patients presented more frequently with overt bleeding (65% vs 15%) and noncirrhotic patients with occult bleeding with iron deficiency anemia (35% vs 85%, P= .01). Endoscopy in noncirrhotic patients revealed more frequently a "watermelon" appearance (23.5% vs 76.9%, P= .008). Endoscopic treatment by APC was successful in 83.3% of patients (88.2% vs 76.9%, not significant). Patients from group 2 required significantly more APC sessions to achieve a complete treatment (2.18 vs 3.77, P= .04).

CONCLUSIONS

APC treatment of bleeding GVE was efficient and safe in cirrhotic and noncirrhotic patients in more than 80% of cases. Noncirrhotic patients required significantly more APC sessions to achieve a complete treatment. An endoscopic watermelon appearance and the use of antiplatelet drugs were associated with failure of APC.

Exercise performance and ventilatory efficiency in patients with mild and moderate liver cirrhosis

1. The impact of ventilatory efficiency on reduced exercise capacity and recovery oxygen kinetics has not been addressed in cirrhotic patients. The aim of the present study was to investigate exercise performance and ventilatory efficiency in patients with mild and moderate liver cirrhosis (LC). 2. Nineteen male non-hypoxic patients with LC (age 51.3 +/- 9.1 years; body mass index (BMI) 25.6 +/- 3.6 kg/m(2)) classified by the Child-Pugh score as class A (n = 7) and class B (n = 12) and 19 age- and BMI-matched controls participated in the study. Subjects undertook maximal incremental exercise testing on a treadmill using the Bruce protocol. 3. Patients with LC showed a reduced diffusion capacity (D(L,CO)%) compared with controls (74.6 +/- 15.2 vs 95.6 +/- 12.9%, respectively; P < 0.001), but a comparable volume standardized diffusion coefficient (1.33 +/- 0.22 vs 1.45 +/- 0.18 mmol/min per kPa per L, respectively; P = 0.74). Patients with LC had a significantly lower exercise capacity compared with controls (VO(2 max) 23.8 +/- 3.8 vs 30.6 +/- 4.4 mL/min per kg, respectively; P < 0.001). Recovery oxygen kinetics were also impaired in LC patients compared with controls (104.6 +/- 19.3 vs 84.4 +/- 22.7 s, respectively; P = 0.012). The chronotropic index was significantly lower in the LC group compared with controls (0.67 +/- 0.19 vs 0.82 +/- 0.17, respectively; P = 0.030) and LC patients showed higher ventilatory equivalents (30.4 +/- 3.8 vs 26.3 +/- 2.3, respectively; P < 0.001) and lower oxygen uptake efficiency slope values (2187 +/- 445 vs 2745 +/- 473 mL/min per log(10)L, respectively; P < 0.001) compared with controls, which is indicative of decreased ventilatory efficiency. Patients with LC also had a higher standardized maximal exercise perception score (SMEPS) compared with controls (0.62 +/- 0.18 vs 0.46 +/- 0.15, respectively; P = 0.011). Moderate negative correlations were found between Child-Pugh score and VO(2 max)% (r = -0.496; P = 0.031). 4. In conclusion, patients with mild and moderate LC have reduced exercise capacity, which correlates with Child-Pugh score, as well as reduced chronotropic index and prolonged recovery oxygen uptake kinetics. The results suggest worsened ventilatory efficiency during exercise and cardiopulmonary reasons for the higher SMEPS in these patients.

Prevalence of gastric varices and portal hypertensive gastropathy in patients with Symmers periportal fibrosis

BACKGROUND AND OBJECTIVE

Symmers periportal fibrosis secondary to schistosomiasis is a common cause of portal hypertension worldwide. Data on the prevalence of gastric varices and portal hypertensive gastropathy in this group of patients with portal hypertension is relatively scarce. The aim of this study was to determine the prevalence of gastric varices and portal hypertensive gastropathy in patients presenting with portal hypertension secondary to Symmers periportal fibrosis.

PATIENTS AND METHODS

In a prospective study, upper gastrointestinal endoscopy was carried out to determine the prevalence of gastric varices and portal hypertensive gastropathy in patients with portal hypertension secondary to Symmers periportal fibrosis.

RESULTS

Of 143 patients studied, 24 patients (16.8%) had gastric varices (grade I in 10.5%, grade II in 6.3%) and 31 patients (21.7%) had portal hypertensive gastropathy (mild in 11.2%, severe in 10.5%). Gastric varices were more prevalent in patients with grade I and II esophageal varices and portal hypertensive gastropathy was more prevalent in those with grade III and IV esophageal varices, but the differences were not statistically significant.

CONCLUSION

We concluded that both gastric varices and portal hypertensive gastropathy seem to have a lower prevalence in patients with portal hypertension secondary to Symmers periportal fibrosis when compared to reported data in patients with portal hypertension secondary to liver cirrhosis and non-cirrhotic portal fibrosis.

Portal hypertensive duodenopathy: clinical, endoscopic, and histopathologic profiles

OBJECTIVE

Description of the clinical, endoscopic, and histopathologic detailed profiles of duodenal affection in portal hypertensive patients.

METHODS

A total of 105 patients with chronic liver disease and portal hypertension (PH) were included, upper endoscopy was performed, and two duodenal biopsies were obtained from the bulb and distal to the ampulla, for histopathologic examination. Twenty dyspeptic patients with normal upper endoscopy were included as controls.

RESULTS

Of the portal hypertensive patients, 54 (51.4%) had endoscopic duodenopathy (ED) lesions including erythema, erosions, ulcers, telangiectasia, exaggerated villous pattern, duodenal varices, and mixed lesions. ED was significantly higher in patients having severe than mild gastropathy (56.8% vs 23.5%, P<0.05) with no relation to size of esophageal varices or variceal bleeding. ED was a source of overt bleeding in 6.7% and occult bleeding in 2.9% of patients. Histopathologically, vascular changes included either capillary congestion (in more than half of biopsies) or capillary angiogenesis (in more than one-quarter of biopsies). Nonvascular changes included increased apoptosis (in about 16% of biopsies), fibrous proliferation (in about 4% of biopsies), and villous changes (in 11.4% of distal biopsies). All changes were not statistically different between patients with and without ED. In dyspeptic patients, only minimal histopathologic changes were noted.

CONCLUSIONS

ED is significantly higher in patients with severe gastropathy and causes gastrointestinal bleeding in 9.5% of patients. Capillary angiogenesis is an important vascular mechanism for adaptation to PH. The overall existence of histopathologic duodenopathy is much higher than that of ED and occurs with a similar prevalence in patients with and without ED.

Inflammation: a way to understanding the evolution of portal hypertension

BACKGROUND

Portal hypertension is a clinical syndrome that manifests as ascites, portosystemic encephalopathy and variceal hemorrhage, and these alterations often lead to death.

HYPOTHESIS

Splanchnic and/or systemic responses to portal hypertension could have pathophysiological mechanisms similar to those involved in the post-traumatic inflammatory response.The splanchnic and systemic impairments produced throughout the evolution of experimental prehepatic portal hypertension could be considered to have an inflammatory origin. In portal vein ligated rats, portal hypertensive enteropathy, hepatic steatosis and portal hypertensive encephalopathy show phenotypes during their development that can be considered inflammatory, such as: ischemia-reperfusion (vasodilatory response), infiltration by inflammatory cells (mast cells) and bacteria (intestinal translocation of endotoxins and bacteria) and lastly, angiogenesis. Similar inflammatory phenotypes, worsened by chronic liver disease (with anti-oxidant and anti-enzymatic ability reduction) characterize the evolution of portal hypertension and its complications (hepatorenal syndrome, ascites and esophageal variceal hemorrhage) in humans.

CONCLUSION

Low-grade inflammation, related to prehepatic portal hypertension, switches to high-grade inflammation with the development of severe and life-threatening complications when associated with chronic liver disease.

The mast cell integrates the splanchnic and systemic inflammatory response in portal hypertension

Portal hypertension is a clinical syndrome that is difficult to study in an isolated manner since it is always associated with a greater or lesser degree of liver functional impairment. The aim of this review is to integrate the complications related to chronic liver disease by using both, the array of mast cell functions and mediators, since they possibly are involved in the pathophysiological mechanisms of these complications. The portal vein ligated rat is the experimental model most widely used to study this syndrome and it has been considered that a systemic inflammatory response is produced. This response is mediated among other inflammatory cells by mast cells and it evolves in three linked pathological functional systems. The nervous functional system presents ischemia-reperfusion and edema (oxidative stress) and would be responsible for hyperdynamic circulation; the immune functional system causes tissue infiltration by inflammatory cells, particularly mast cells and bacteria (enzymatic stress) and the endocrine functional system presents endothelial proliferation (antioxidative and antienzymatic stress) and angiogenesis. Mast cells could develop a key role in the expression of these three phenotypes because their mediators have the ability to produce all the aforementioned alterations, both at the splanchnic level (portal hypertensive enteropathy, mesenteric adenitis, liver steatosis) and the systemic level (portal hypertensive encephalopathy). This hypothetical splanchnic and systemic inflammatory response would be aggravated during the progression of the chronic liver disease, since the antioxidant ability of the body decreases. Thus, a critical state is produced, in which the appearance of noxious factors would favor the development of a dedifferentiation process protagonized by the nervous functional system. This system rapidly induces an ischemia-reperfusion phenotype with hydration and salinization of the body (hepatorenal syndrome, ascites) which, in turn would reduce the metabolic needs of the body and facilitate its temporary survival.

[Role of capsule endoscopy in patients with portal hypertension and obscure gastrointestinal bleeding]

BACKGROUND AND AIMS

Limited number of data are available on small bowel changes due to portal hypertension. The present retrospective, comparative study was aimed to analyse the diagnostic yield and to describe the findings with capsule endoscopy of cirrhotic patients with obscure gastrointestinal bleeding.

PATIENTS AND METHODS

Capsule endoscopy findings of 11 cirrhotic patients with portal hypertension and 22 non-cirrhotic patients with gastrointestinal bleeding who had undergone non-diagnostic upper endoscopy and colonoscopy were compared. Capsule video recordings were evaluated by two investigators at both workplaces. Patients after capsule endoscopy were followed-up until a mean of 19 (1-42) months.

RESULTS

In total 7 men and 5 women were examined at two medical centres in 48 months with a mean age of 66.2 (+/-7.6) years. The average period between the first clinical symptoms and capsule endoscopy was 15.7 (+/-14.9) months. During this period patients were hospitalized in an average of 2.8 (+/-1.3) times and 7.9 examinations were performed per patients prior to capsule endoscopy. A small bowel bleeding source was diagnosed in all 11 patients. Two definitive bleeding sources were observed in 7 patients (63%). Lesions connected to portal hypertension were found in all patients (8 angiodysplasias, 2 portal hypertensive enteropathies and 1 bowel varix). During the follow-up period rebleeding occurred in 27.3% of cirrhotic patients compared with 18.2% rebleeding rate in the control group.

CONCLUSION

Capsule endoscopy is a useful method in patients with portal hypertension and obscure gastrointestinal bleeding after negative upper endoscopy and colonoscopy. Multiple angiodysplasias are often diagnosed in the background of small bowel bleedings, and several bleeding sources frequently occur in these patients.

The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration

BACKGROUND

The purpose of our study was to evaluate the long-term outcome and complications of balloon-occluded retrograde transvenous obliteration (B-RTO) in patients with hemorrhage from gastric fundal varices.

METHODS

Thirty-four consecutive patients with bleeding from gastric varices who were treated with B-RTO were enrolled in this study between December 1994 and September 2005 (urgent cases, n = 12; elective cases, n = 22). The long-term outcome, complications, and various liver functions were evaluated.

RESULTS

Complete obliteration was achieved in 31 of 34 (91%) patients with an acute bleeding episode. In one of the remaining patients, there was a technical failure, and the other two had only partial obliteration. The two patients with partial obliteration did not obtain hemostasis. Thus, the rate of hemostasis was 94% (31/33). Gastric varices disappeared in all patients with complete obliteration during the treatment. The rate of gastric variceal eradication was 91%. Variceal rebleeding from esophageal varices occurred in three patients. The rate of rebleeding was 10% (3/31). Rebleeding from gastric varices was not observed after complete obliteration. None of the patients showed worsening of their Child-Pugh score. Although the 5-year cumulative worsening rate of esophageal varices was 52%, neither portal hypertensive gastropathy nor ectopic varices were observed. The patients with worsening esophageal varices were successfully treated with an endoscopic procedure. The 5-year survival rate was 68%.

CONCLUSIONS

B-RTO is useful for treatment of bleeding gastric varices, achieving high eradication of gastric varices, a low rebleeding rate, and a fairly good prognosis with improved hepatic function.

[Portal hypertension in mansonic schistosomiasis: repercussions of surgical treatment on the histomorphometric profile of the gastric mucosa]

The repercussions from surgical treatment for controlling portal hypertension and its effects on the gastric vasculature of young patients with mansonic schistosomiasis were investigated by digital image analysis. The study included five patients at the preoperative stage and 27 patients who had undergone surgical intervention at different times in the past: 0-2 years ago, n=4; 2-6 years ago, n=13, and more than 6 years ago, n=10. Endoscopic biopsies were taken from the mucosa of the gastric antrum and body endoscopic mucosa and the samples underwent routine histological tests after embedding in paraffin blocks. Histological thin sections were used for histomorphometric analysis of the following parameters: mean number of vessels per field, and mean diameter and thickness of the vessel walls. The results showed that, between the patients whose operation was not more than two years ago and those whose operation was more than six years ago, there was a significant decrease in the density and diameter of the vessels. These findings give support to the concept that the surgical treatment administered decreases specific histological alterations like hemorrhage and ectasia, over the long term.

Gastropathy and gastritis in children with portal hypertension

The aim of this study was to determine the frequency of portal hypertensive gastropathy (PHG) and gastritis in children with portal hypertension and related factors. The study included 24 children with portal hypertension secondary to liver disease or extrahepatic venous obstruction. PHG was seen in 14 of 24 patients. PHG was significantly associated with the presence of esophageal varices and a history of hematemesis. Histologically, gastritis was identified in 14 of 24 patients and was significantly associated with cirrhosis. PHG is frequently found in children with portal hypertension, and it develops regardless of the cause of the portal hypertension.

Portal hypertensive duodenal polyp: A case report

Abnormalities of gastric mucosa in patients with portal hypertension are well documented. Manifestations of portal hypertension in small bowel and colon are less common. Colonic polypoid lesions microscopically consisting of a normal mucosa, with dilatation of submucosal vessels, have been described. We here report the first case of portal hypertensive duodenal polyp, responsible for gastro-intestinal bleeding. Endoscopic treatment turned out to be successful.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension.

METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B).

RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups.

CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but the former results in fewer and milder complications.

Diagnosing and treating bleeding portal hypertensive duodenopathy

Portal hypertensive duodenopathy is a rare condition related to liver cirrhosis; there is little in the literature about its clinical significance and management. It seems to be endoscopically and histologically similar to portal hypertensive gastropathy, which is well defined. We report the case of a patient, initially treated for acute bleeding resulting from the rupture of esophageal varices, who developed an atypical endoscopic picture of portal hypertensive duodenopathy over a 6-month period. After microscopic definition of the disease we found chronic bleeding which required blood transfusions. Medical treatment did not solve the problem. We describe an approach using the argon plasma coagulator.

Consequences of living-donor liver transplantation for upper gastrointestinal lesions: high incidence of reflux esophagitis

There is little information available regarding the consequences of living-donor liver transplantation (LDLT) for upper gastrointestinal lesions. We retrospectively compared the pre- and posttransplant incidences of noninfectious reflux esophagitis, portal hypertensive gastropathy (PHG), esophageal varix, gastroduodenal ulcer, Helicobacter pylori infection, and abnormal gastroesophageal valve in 29 adult patients (16 males, 13 females) who underwent LDLT for end-stage liver disease. Here we present four findings from this study. First, the posttransplant incidence of noninfectious esophagitis was significantly higher than the pretransplant incidence (27.6% vs. 3.4%; P < 0.001), irrespective of postoperative use of standard-dose H2RA. Second, PHG and esophageal varix, which were noted in 65.5% and 96.6% of pretransplant recipients, respectively, spontaneously resolved postoperatively in all cases. Third, H. pylori infection, which was observed in 50.0% of preoperative recipients, decreased to 5.6% postoperatively, although no significant difference was observed between the pre- and the posttransplant incidences of gastroduodenal ulcer (6.9% vs. 6.9%). Finally, the incidence of abnormal gastroesophageal valve did not change following LDLT (34.5% vs. 34.5%). In conclusion, this study suggests that noninfectious reflux esophagitis occurs more frequently following LDLT. Although the disease is the results of a very complex interaction of various factors, spontaneous resolution of PHG and serendipitous H. pylori eradication might have contributed to increased incidence of postoperative esophagitis, possibly through gastric acid hypersecretion. In contrast, morphological change of the gastroesophageal valve was not considered to be the cause of this disease. Because this study was a retrospective analysis of a small population of LDLT recipients, prospective randomized controlled studies of a sufficient number of cases are required to substantiate these conclusions.

Prevalence of portal hypertensive duodenopathy in cirrhosis: clinical and haemodynamic features

OBJECTIVES

To estimate the prevalence of portal hypertensive duodenopathy (PHD) in patients with cirrhosis and portal hypertension, and to evaluate its relationship with clinical and haemodynamic parameters.

PATIENTS AND METHODS

Endoscopy reports and clinical history of 549 consecutive patients with cirrhosis and portal hypertension were evaluated retrospectively. A diagnosis of PHD was obtained in those patients with a congestive vascular pattern of the duodenum.

RESULTS

PHD was found in 46 patients (8.4%). Previous endoscopic band ligation and coexistence of severe gastropathy were significantly more frequent in PHD group. Systemic and hepatic haemodynamic evaluations were performed in 20 patients with PHD and 160 without PHD: the mean hepatic venous pressure gradient was higher in those cases with PHD (22.5 (5.4) vs. 19.8 (5.5) mmHg, P=0.045). Hypertensive colopathy was found in seven out of the 10 patients with PHD and a colonoscopic evaluation. In five of six patients PHD disappeared after liver transplant.

CONCLUSIONS

PHD is an uncommon finding of portal hypertension in cirrhotic patients. It is associated with previous endoscopic band ligation, to manifestations of portal hypertension in other sites of the gastrointestinal tract and to greater values of hepatic venous pressure gradient. The clinical relevance of this syndrome remains to be determined.

Portal hypertension-related bleeding: management of difficult cases

Many advances have occurred in the management of varices over the years. Guidelines based on sound evidence have been developed to manage the esophageal variceal hemorrhage. Less is known about how best to manage some of the more difficult cases of bleeding related to portal hypertension. This article reviews evidence in the hypertensive gastropathy, ectopic varices, and management of patients who are intolerant of or have not responded to beta-blocker therapy. The goal of this article is to review the sparse available evidence and to suggest reasonable management options.

Portal hypertensive enteropathy

The available data on the use of VCE in patients who have cirrhosis and portal hypertension are inadequate to reach a firm conclusion about the usefulness of this diagnostic tool in this patient population. In fact, only retrospective case series exist, in which the characteristics of the patients are heterogeneous in terms of severity of liver disease and of portal hypertension, etiology of cirrhosis, and indication for VCE. In addition, the controls included in the studies are heterogeneous or poorly described. In spite of this, it appears that in patients with portal hypertension, the small bowel frequently shows mucosal abnormalities. Such abnormalities appear to be particularly frequent in patients who have severe portal hypertension and in those with low hemoglobin levels. The clinical significance of these findings remains undefined, however, especially in view of the fact that small bowel lesions also have been found in about 10% of patients with arthritis not taking nonsteroidal anti-inflammatory drugs and in 13.8% of healthy subjects [41,42]. Therefore,large prospective studies are needed to evaluate the prevalence and clinical significance of small bowel mucosal changes in patients who have cirrhosis. Such studies should compare patients who have cirrhosis with healthy subjects. A comparison between cirrhotic patients with a history of intestinal bleeding and bleeding patients without cirrhosis also would be interesting.

Perméabilité intestinale et cirrhose

Patients with cirrhosis are at increased risk of developing infections due to bacterial translocation. This process depends on three principal factors: bacterial overgrowth, immunodepression, and altered intestinal permeability. Intestinal barrier functions may be disturbed in cirrhosis, related to the toxic effects of alcohol (on mucosa and biological membranes) and portal hypertensive enteropathy. Few studies on the assessment of intestinal permeability in cirrhotic patients are available, and contradictory results may be explained by methodological differences. However, four studies using a differential sugar absorption test (lactulose-mannitol test, a combination of an oligosaccharide and a monosaccharide) showed an increased intestinal permeability in cirrhotic patients. The recurrence of spontaneous bacterial peritonitis can be appreciated only by one similar case history, a low rate of protides in ascites (<10 g/L), bilirubinemia > 55 micromol/L, and thrombocytopenia<98.000/mm3. These results suggest that primary antibiotherapy prophylaxis should be recommended, but this recommendation is limited by the risk of bacterial resistant selection and by the fact that no patient survival benefits was shown. Intestinal permeability could be another predictive factor to justify preventive antibiotherapy; but more studies are needed and methods should be standardized (technique used to measure permeability, patient groups involved).

Is there ileopathy in portal hypertension?

BACKGROUND AND AIMS

Portal hypertensive gastropathy and colopathy are well described endoscopic abnormalities in patients with portal hypertension. Endoscopic abnormalities in the ileum in patients with portal hypertension have not been well described. The aim of the present study was to evaluate endoscopic abnormalities in the ileum of patients with portal hypertension.

METHODS

Patients with portal hypertension of various etiologies were included in the study. Upper gastrointestinal endoscopy was performed to record esophageal varices, gastric varices and portal hypertensive gastropathy. Colonoscopy with retrograde intubation of the ileum was performed and the presence of colorectal varices, colopathy and mucosal findings in the ileum were noted.

RESULTS

Forty-one patients (age 16-80 years, 33 men) were studied. Esophageal varices were present in all. Portal hypertensive gastropathy was present in 27/41 (66%) patients. Rectal varices were noted in 22/41 (54%) patients and 17/41 (42%) patients had features suggestive of colopathy. Ileum could be intubated in 38 patients (93%). Endoscopic abnormalities in the ileum were noted in 13/38 (34%) patients. Ileopathy as evident by endoscopic mucosal abnormalities was observed in 10/38 (26%) patients. Ileal varices were present in 8/38 (21%) patients. Three of these had ileal varices alone while the remaining five patients also had associated ileopathy The presence of ileopathy was significantly associated with the presence of portal hypertensive gastropathy and colopathy but not with esophageal, gastric or rectal varices.

CONCLUSIONS

Ileopathy occurs in one-third of patients with portal hypertension and is significantly associated with the presence of portal hypertensive gastropathy and colopathy.

EFFECT OF ISOSORBIDE DINITRATE ON GASTRIC BLOOD FLOW IN RATS WITH LIVER CIRRHOSIS DETERMINED BY ANALYZING GASTRIC BLOOD FLOW, PORTAL VEIN PRESSURE AND BLOOD GAS

We investigated the effects of isosorbide dinitrate (IDN) on gastric blood flow (GBF), portal venous pressure (PVP) and blood gas of rats with liver cirrhosis (LC) accompanied by portal hypertension. Thirty male Wistar rats (LC in 17 and normal in 13) were used. Before and after IDN administration, GBF, PVP and blood gas in the femoral artery and portal vein were measured. Portal blood oxygen concentration was estimated by calculating the ratio of PO2 in portal blood and that in arterial blood (PpvO2/PaO2) of each rat. The GBF in the LC rats was significantly lower than that in the normal rats. In the LC group, IDN administration significantly increased the GBF. The PpvO2/PaO2 value in the group with LC was significantly lower after IDN administration than that before IDN administration. In the investigation whether changes in PVP or Ppv/PaO2 contributed more to the change in GBF after IDN administration, a significant correlation was found between rates of change in GBF and PpvO2/PaO2 were significantly correlated (r= -0.733, p <0.05). The effect of IDN on changes in the stomach accompanying portal hypertension is mainly attributable to a decrease in preload, which suppresses inflow to the stomach, as reflected by a decrease in PpvO2/ PaO2, rather than to a decrease in afterload on GBF, as reflected by a decrease in PVP.

Expression of endothelin receptors in the gastric mucosa of portal hypertensive rats

BACKGROUND

Portal hypertensive gastropathy is an abnormal circulatory state in gastric mucosa with vascular dilatation due to portal hypertension. The aim of the present study was to evaluate expression of endothelin receptors and their roles in the portal hypertensive gastric mucosa.

METHODS

Portal hypertensive rats were generated by staged portal vein occlusion. Expression of endothelin-A receptor and endothelin-B receptor mRNA was examined by reverse transcriptase-polymerase chain reaction, and protein were examined by immunohistochemistry. The changes of mucosal microcirculation by endothelin receptor antagonists were measured with in vivo microscope.

RESULTS

Expression of endothelin-A receptor mRNA was increased significantly in portal hypertensive rats in comparison with sham-operated control rats (P < 0.05). There was no significant difference between the two groups in endothelin-B receptor mRNA expression. Vessels of the gastric mucosa were dilated, and intravessel blood flow was increased significantly in the portal hypertensive group (P < 0.05). Diameters of mucosal vessels and blood flow were increased significantly by endothelin-A receptor antagonist (BQ-485) in the portal hypertensive rats. Endothelin-B receptor antagonist (IRL-1038) had no significant effect on mucosal microcirculation.

CONCLUSION

These data suggest that increased expression of endothelin-A receptor in the portal hypertensive gastric mucosa may be related to the regulation of gastric microcirculation.

Bleeding caused by portal hypertension

Variceal bleeding is one of the dreaded complications of portal hypertension. Patients who have suspected or proven cirrhosis should undergo diagnostic upper endoscopy to detect medium and large gastro-esophageal varices. Patients with medium and large gastro-esophageal varices should be treated with non-selective beta-blockers (propranolol or nadolol), and these agents should be titrated to a heart rate of 55 beats per minute or adverse effects. If there are contraindications to or if patients are intolerant to beta-blockers, it is appropriate to consider prophylactic banding therapy for individuals with medium-to-large esophageal varices. When patients who have cirrhosis present with GI bleeding, they should be resuscitated and receive octreotide or other vasoactive agents. Endoscopy should be performed promptly to diagnose the source of bleeding and to provide endoscopic therapy (preferably banding). The currently available treatment for acute variceal bleeding provides hemostasis in most patients. These patients, however, are at significant risk for rebleeding unless secondary prophylaxis is provided. Although various pharmacological, endoscopic, radiological, and surgical options are available, combined pharmacological and endoscopic therapy is the most common form of secondary prophylaxis. TIPS is a radiologically placed portasystemic shunt, and if placed in suitable patients, it can provide effective treatment for patients with variceal bleeding that is refractory to medical and endoscopic therapy.

N/A

N/A

Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study

BACKGROUND

The frequency of small-bowel mucosal changes in patients with portal hypertension is not known. The objective of the study is to better define the mucosal abnormalities of portal hypertensive enteropathy (PHE) and to determine whether these findings are associated with the severity of liver disease, esophageal varices, portal gastropathy, portal colonopathy, or other clinical characteristics.

METHODS

We compared the medical records of 37 patients with cirrhosis and portal hypertension with 34 control patients who underwent capsule endoscopy over a 3-year period.

RESULTS

Mucosal changes were found to be significantly more common in the cirrhotic patients than in the control patients (67.5% vs. 0, p < 0.001). The lesions included telangiectasias or angiodysplastic-like lesions in 9 (24.3%) patients, red spots in 23 (62.2%), and varices in 3 (8.1%). Active bleeding was seen during endoscopic examinations in 4 (10.8%) patients. A comparison of patients with and those without PHE showed that grade 2+ or larger esophageal varices, portal gastropathy, portal colonopathy, and Child-Pugh class C cirrhosis were all significantly associated with PHE. There were no differences between these two groups of patients with regard to the etiology of cirrhosis, gender, or history of esophageal variceal bleeding.

CONCLUSIONS

Mucosal abnormalities in portal jejunopathy include edema, erythema, and vascular lesions findings. A standardized grading system to classify the endoscopic appearance and the severity of portal enteropathy is proposed. The clinical import of these changes remains to be explained.